Health inspection·July 23, 2025

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. Based on interview and record review the facility failed to ensure psychotropic medications were prescribed for a defined duration for 1 of 5 residents (R12) reviewed for unnecessary medications in the sample of 18.The findings include:R12's Order Summary Report dated 7/23/25 shows R12 has an order for a psychotropic medication (Diazepam) to be administered as needed. The start date for the order was 3/10/25. There is no end date. On 7/23/25 at 10:10 AM, V9, MDS Coordinator, said psychotropic medications ordered as needed can only be prescribed for a duration of 14 days, then a new order must be obtained. The facility's Psychotropic Medication Use Policy (undated) shows psychotropic medications are subject to prescribing, monitoring and review requirements; psychotropic medication management includes duration. Page 1 of 13 145556 145556 07/23/2025 Winning Wheels 701 East 3rd Street Prophetstown, IL 61277

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to complete a Preadmission Screening and Resident Review (PASARR) Level 2 screen after a resident that was diagnosed with schizoaffective disorder diagnoses which applies to 1 of 18 residents (R7) reviewed for PASARR assessments in a sample of 18.The findings include:R7's Facesheet printed on 7/23/25 showed R7 is a sixty-year-old male originally admitted to the facility on [DATE].R7's Physician Summary notes dated 3/31/2020 showed R7's schizoaffective disorder diagnosis onset is dated 4/17/2019.R7's electronic record showed no PASARR level 2 was completed after R7 received the new diagnosis of schizoaffective disorder.The facility's PASARR Policy dated 2024 showed a resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or related conditions will be referred promptly to the state mental health or intellectual disability authority for a level 2 resident review.On 7/23/25 at 2:00 pm, V1 Administrator stated a resident with a new mental disorder diagnoses needs a level 2 PASARR assessment. 145556 Page 2 of 13 145556 07/23/2025 Winning Wheels 701 East 3rd Street Prophetstown, IL 61277

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a dressing was in place for a resident with a stage 4 pressure injury for one of one resident (R71) reviewed for pressure injuries in the sample of 18.The findings include:R71's Order Summary Report dated July 22, 2025 shows he was admitted to the facility on [DATE] with diagnoses including spina bifida, urinary tract infections, wheelchair dependence, pressure injury of left buttock stage four, and malnutrition. Orders for calcium alginate apply to left buttock topically every day shift started July 14, 2025.On July 21, 2025 at 10:18 AM, V8 Certified Nursing Assistant placed R71 into the shower chair and placed him in the shower so he could shower himself. At 10:49 AM, V8 placed R71 back into bed and dried off R71's body and got him dressed. There was a dressing that came off of R71's left buttock. The wound to R71's left buttock had some depth to it and was a little bigger than a quarter size in diameter. V8 put a shirt onto R71 and said she was waiting for the wound doctor to come to replace the dressing. R71 was positioned in bed onto his back with no dressing on his buttocks. At 2:26 PM, V8 said the wound care doctor is in the building but is on a different hallway and has not been to R71's room yet. At 2:35 PM, R71 said no staff have replaced the dressing on his left buttock. R71 said he is still in bed because they are waiting for the wound doctor to replace the dressing. R71 said he prefers to be in his wheelchair and not in the bed.R71's Treatment Administration Record dated July 1, 2025-July 31, 2025 shows R71's dressing to his left buttock was not documented as done on July 18, 2025 and July 21, 2025.R71's Wound Evaluation Management Summary dated July 21, 2025 at 3:35 PM shows that R71 has a stage four pressure injury to his left buttock that measured 4.2 X 3.5 X 3.5 cm. Dressing treatment plan was alginate calcium apply once daily and as needed; if saturated, soiled, or dislodged. Secondary dressing was gauze island with border apply once daily and as needed if saturate, soiled, or dislodged.On July 23, 2025 at 9:27 AM, V2 Director of Nursing (DON) said dressings should be replaced to pressure injuries if they come off.The facility's Prevention of Pressure Injuries policy dated April 2020 shows, Review the resident's care plan and identify the risk factors as weel as the interventions designed to reduce or eliminate those considered modifiable. Use facility-approved protective dressings for at risk individuals. Residents Affected - Few 145556 Page 3 of 13 145556 07/23/2025 Winning Wheels 701 East 3rd Street Prophetstown, IL 61277

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident was transferred in a safe manner for 1 of 18 residents (R73) in the sample of 18 reviewed for safety.The findings include:On 7/21/25 at 11:03 AM, R73 was sitting in a recliner in the TV room. V12, Certified Nursing Assistant (CNA), was pulling R73's left arm to get him out of the recliner. R73's left arm was pulled to the point where his left elbow was above the level of his head. On 7/23/25 at 9:30 AM, V2, Director of Nursing (DON), said a gait belt should be used to help pull a resident out of their chair. A resident's arm should not be pulled because it could cause an injury. R73's admission Record dated 7/23/25 shows he was admitted to the facility on [DATE]. R73's diagnoses include, but are not limited to, traumatic brain injury, quadriplegia, and repeated falls. R73's current care plan provided by the facility shows R73 has limited mobility, decreased strength, history of falls, and decreased sitting and standing balance and requires assistance with ambulation and transfers. The facility's Safe Resident Handling/Transfers Policy (undated) shows all residents require safe handling when transferred to prevent or minimize the risk for injury. 145556 Page 4 of 13 145556 07/23/2025 Winning Wheels 701 East 3rd Street Prophetstown, IL 61277

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to date and time liquid nutrition when it was initiated for 1 of 4 residents (R34) reviewed for tube feeding in the sample of 18.The findings include:R34's Order Summary dated July 22, 2025 shows R34 was admitted to the facility on [DATE] with diagnoses including intracranial injury with loss of consciousness, dysphagia, pain, contractures, aphasia, and epilepsy. A liquid nutrition order was entered on November 22, 2024 for Isosource 1.5 two times per day.On July 21, 2025 at 9:39 AM, there was a bag of liquid nutrition hanging next to R34's bed. There was no resident's name on the bag nor date nor time. There was liquid nutrition noted in the tubing and the bag of nutrition was half empty. At 1:05 PM, this same unlabeled bag was still hanging next to R34's bed.On July 23, 2025 at 9:27 AM, V2 Director of Nursing said the liquid nutrition should be labeled with the date and time it was hung, the type of liquid nutrition, and the resident's name.The facility's Tube Feeding Policy and Procedure effective November 2012 shows, To provide a means of safely introducing a complete nutritional feeding to the resident, using a formula that is premixed and premeasured in a specifically designed container with a bacterial filter to protect the formula from being exposed to harmful airborne contaminates. Procedure using clean technique, write the date, and initials on the label provided on the tubing of the pump set and enter the residents name, room number, date, start time, rate and initials on the identification information label on the bottle of tube feeding. 145556 Page 5 of 13 145556 07/23/2025 Winning Wheels 701 East 3rd Street Prophetstown, IL 61277

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer a medication as ordered by the physician for one of 18 residents (R3) reviewed for pharmacy services in the sample of 18. The findings include:R3's Order Summary Report shows she was admitted to the facility on [DATE] with diagnoses including myocardial infarction, congestive heart failure, generalized anxiety disorder, major depressive disorder, pain, major depressive disorder, post-traumatic stress disorder, alcohol use, and other bipolar disorder.On July 22, 2025 at 10:39 AM, R3 said it takes the facility a long time to start new medication orders. R3 said the psych doctor ordered an increase in her trazodone but she did not get the medication when it was ordered. I take it to help me sleep.R3's note from the psychiatry nurse practitioner dated July 10, 2025 shows, Plan Med changes: Patient's diagnosis of major depressive disorder is worsening and unstable at this visit. Increase trazodone to 100mg by mouth at bedtime.R3's Order Summary Report shows an order for trazodone 100mg (milligrams) one tablet by mouth at bedtime for mood related to major depressive disorder was entered July 11, 2025 to start on July 11, 2025.R3's Medication Administration Record (MAR) dated July 1, 2025-July 31, 2025, shows she received trazodone 75 mg from July 1, 2025-July 10, 2025 as ordered. The new order for the increase in trazodone to 100mg at bedtime was to start July 11, 2025. R3's MAR shows that R3 did not receive trazodone 100mg until July 13, 2025. R3's Psychotropic Informed Consent form for the increase in trazodone was signed by R3 on July 13, 2025.On July 23, 2025 at 9:27 AM, V2 Director of Nursing (DON) said she did not know why R3 had not received her increase dose of trazodone.The facility's Medication and Treatment Orders policy revised July 2016 shows, Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. 145556 Page 6 of 13 145556 07/23/2025 Winning Wheels 701 East 3rd Street Prophetstown, IL 61277

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review the facility failed to ensure a multidose insulin pen was discarded 28 days after being opened for 1 of 18 residents (R3) reviewed for medication storage in the sample of 18. The findings include:On 7/21/25 at 10:13 AM, R3's Lispro Insulin Pen was in the medication cart. The pen was labeled with an open dated of 6/15/25 and there was no discard date documented. 07/21/2025 10:13 AM, V7 (Licensed Practical Nurse) said that all insulin pens should be marked with the open date when it is opened and a discard date should be documented for 28 days after the date that it was opened. R3's July Medication Administration Record shows that she received Lispro Insulin Pen five times between 7/13/25 and 7/21/25. The facility's Insulin Pen Policy shows, Insulin pens must be clearly labeled with the resident name, physician name, date dispensed, type of insulin, amount to be given, frequency and expiration date Insulin pens should be disposed according to manufacturer's recommendations. The Lispro Manufacturer Guidelines show, Throw away the Insulin Lispro Pen you are using after 28 days, even if it still has insulin left in it. 145556 Page 7 of 13 145556 07/23/2025 Winning Wheels 701 East 3rd Street Prophetstown, IL 61277

F 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide dental services for a resident which applies to 1 of 1 resident (R49) reviewed for dental services in a sample of 18.The findings include:R49's Facility assessment dated [DATE] showed R49 is a thirty-nine-year-old male resident with moderate cognitive impairment. R49 was admitted to the facility on [DATE] with diagnoses which include hemiplegia/hemiparesis and intercranial injury.On 07/21/2025 at 2:00 PM, R49 was sitting in their wheelchair watching television. R49 had several broken teeth on their upper jaw, and dark colored tooth fragments/tooth roots along their lower jaw.R49's electronic medical record showed the last dental consent and appointment notes were dated 10/20/2020.On 7/23/25 at 1:50 PM, V11 Social Services stated we set up in house or out of house services for dental work. R49 does get seen out of the facility for dental services. V11 stated R49 does have broken teeth and gum issues. V11 stated they were not aware R49 has not seen a dentist since 2020.The facility's Dental Policy dated 2025 showed the facility is to assist residents with obtaining routine (covered by the State plan) and emergency dental care.On 7/23/25 at 2:00 PM, V1 Administrator stated they had no other documentation of R49 receiving dental care since 10/20/2020. Residents Affected - Few 145556 Page 8 of 13 145556 07/23/2025 Winning Wheels 701 East 3rd Street Prophetstown, IL 61277

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview and record review the facility failed to follow the pureed diet menu for 4 of 4 residents (R4, R16, R38 and R42) reviewed for menus in the sample of 18. The findings include:The facility provided Diet Type Report printed on 7/22/25 shows that R4, R16, R38 and R42 are all on a pureed diet.The Diet Spreadsheet for the noon meal on 7/21/25 shows that residents on a pureed diet should receive pureed barbecue on cornbread, pureed green beans and pureed canned fruit.The Recipe for Pureed Barbecue Pork on Cornbread shows ingredients of: BBQ Pork on cornbread with creamed corn and milk.On 7/21/25 at 10:42 AM, V15 (Cook) prepared the pureed food for the noon meal. V15 placed 10 scoops of barbecue pork into the blender bowl and processed it. V15 added warm milk and processed again. V15 then place the pureed barbecue into a container and placed it onto the steam table. V15 did not add cornbread to the barbecue. On 7/21/25 at 11:37 AM, R4, R16, R38 and R42 were served the pureed barbecue without a cornbread serving. V15 then ran out of pureed barbecue and prepared additional barbecue by adding corn bread into the barbecue. On 7/22/25 1:10 PM, V4 (Dietary Manager) said that the menu and recipe should be followed by the staff when making pureed food. V4 said that the pureed barbecue should have had corn bread added to it during the puree process. The facility's Puree Food Preparation Policy shows, Puree Food Preparation Guidelines for serving per individual recipes. 145556 Page 9 of 13 145556 07/23/2025 Winning Wheels 701 East 3rd Street Prophetstown, IL 61277

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview and record review the facility failed to ensure residents on a pureed diet were served a meal in a form that meet their needs for 4 of 4 residents (R4, R16, R38 and R42) reviewed for pureed diets in the sample of 18. The findings include:The facility provided Diet Type Report printed on 7/22/25 shows that R4, R16, R38 and R42 are all on a pureed diet.The Diet Spreadsheet for the noon meal on 7/21/25 shows that residents on a pureed diet should receive pureed barbecue on cornbread, pureed green beans and pureed canned fruit and an alternative of pureed breaded fish and pureed potatoes. On 7/21/25 at 10:42 AM, V15 (Cook) prepared the pureed food for the noon meal. V15 pureed breaded fish sticks and added warm milk. V15 then placed the pureed fish into a container. When scooped into the container, the fish appeared very thick. V15 then pureed barbecue pork and added warm milk. V15 then placed the barbecue into a container. When scooped into the container, the barbecue appeared thick. On 7/21/25 at 11:37 AM, R4, R16, R38 and R42 were served the pureed meal. On 7/21/25 at 12:15 PM, the pureed fish and barbecue was tasted. The fish and barbecue were thick, dry and not a smooth consistency. On 7/22/25 1:10 PM, V4 (Dietary Manager) said that pureed foods should be pureed to a smooth, pudding like consistency. The facility's Puree Food Preparation Policy shows, Puree foods should be prepared in such a manner to prevent lumps and chunks. The goal is a smooth, soft, homogenous consistency similar to soft mashed potatoes. 145556 Page 10 of 13 145556 07/23/2025 Winning Wheels 701 East 3rd Street Prophetstown, IL 61277

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a meal was served in a sanitary manner and failed to ensure the temperature of resident refrigerators were monitored. This has the potential to affect all 77 residents residing in the facility. The findings include: 1. On 7/21/25 at 11:30 AM, V15 (Cook) was plating the noon meal from the steam table. V15 had gloves on and was putting the fish sticks and cornbread onto the plates using her hands. At 11:45 AM, V15 coughed onto her right wrist area. At 11:49 AM, V15 sneezed into her left elbow area. At 11:51 AM, V15 wiped her nose with her left wrist area. V15 continued to serve the food with her hands and did not remove her gloves and perform hand hygiene. On 7/22/25 1:10 PM, V4 (Dietary Manager) said that staff should always be using utensils to serve food to the residents. V4 said that if the staff coughs or sneezes while plating food, they should leave the line and wash their hands and put a new pair of gloves on. The facility's Handwashing Guidelines for Dietary Employees shows, Dietary employees shall keep their hands and exposed portions of their arms clean .Dietary employees shall clean their hands and exposed portions of their arm immediately before engaging in food preparation including working with exposed food .and also in the following situations: After coughing, sneezing, or blowing your nose . 2. R30’s Facility assessment dated [DATE] showed R30 is a fifty-one-year-old cognitively intact female resident admitted to the facility on [DATE]. On 7/21/25 at 10:15 AM R30’s room refrigerator had no thermometer in it. The refrigerator had 2 yogurt containers, lunchmeat, and sliced cheese. R30 stated she did not remember the last time any of the staff had checked the refrigerator. R30 stated there has not been a thermometer in it in a long time. 3. R2’s Facility assessment dated [DATE] showed R2 is a forty-eight-year-old cognitively intact female resident admitted to the facility on [DATE]. On 7/21/25 at 1:25 PM, R2’s refrigerator had no thermometer in it. The freezer/fridge had an open ice cream container, an opened heart (Valentine’s Day) candy box, yogurt, guacamole, and assorted small candies. R2 stated they did not know if/when anybody has checked the fridge. R2 stated when she gets food leftovers they put it in the refrigerator. On 7/23/25 at 10:20 AM, V10 Safety Director stated they do room checks, but do not have documentation for the resident room refrigerators. They should all have a thermometer in them to make sure they are working. The facility’s undated Resident Food Storage and Handling Policy showed the facility ensure proper handling, serving a storage of any food items brought into the facility. 145556 Page 11 of 13 145556 07/23/2025 Winning Wheels 701 East 3rd Street Prophetstown, IL 61277

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to change their gloves and perform hand hygiene in a manner to prevent cross contamination for one of 18 residents (R34) reviewed for infection control in the sample of 18.The findings include:R34's Order Summary Report dated July 22, 2025 shows she was admitted to the facility on [DATE] with diagnoses including intracranial injury with loss of consciousness, insomnia, dysphagia, atopic dermatitis, and neuromuscular dysfunction of the bladder.R34's Care Plan initiated on April 20, 2020 shows R34 has bowel and bladder incontinence. R34's Care Plan initiated on April 15, 2025 shows R34 is on enhanced barrier precautions and ensure proper hand washing is completed as resident allows.On July 21, 2025 at 9:39 AM, V5 and V6 Certified Nursing Assistants (CNAs) provided incontinence care to R34. V6 CNA removed R34's incontinence brief. There was a large amount of urine in R34's incontinence brief. V6 then touched the mechanical lift sling to place underneath R34, touched the mechanical lift sling controls to elevate R34 and place her into the shower chair. V6 then showered R34. V6 did not change her gloves while doing the above.On July 23, 2025 at 9:27 AM, V2 Director of Nursing (DON) said gloves should be changed prior to touching any clean items when doing incontinence care.The facility's Handwashing/Hand Hygiene policy revised October 2023 shows, This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Hand Hygiene is indicated after contact with blood, body fluids, or contaminated surfaces and before moving from work on a soiled body site to a clean body site. Residents Affected - Few 145556 Page 12 of 13 145556 07/23/2025 Winning Wheels 701 East 3rd Street Prophetstown, IL 61277

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents rooms were free from pests which applies to 2 of 18 residents (R46, R54) reviewed for pest control is a sample of 18.The findings include:The facility's resident roster dated 7/16/25 showed R46 and R54 are roommates on the B-wing of the facility.R46's Facesheet printed on 7/22/25 showed R46 is a [AGE] year-old male with diagnoses which include tracheostomy, traumatic brain injury, and hemiplegia of the left side.On 7/21/25 at 10:30 AM, R46 was lying in bed with no shirt on. R46 had 4-6 flies flying around bed area and landing and walking on R46. R46 was having difficulty waving the flies off himself. R46 nodded when asked if the flies were bothering him. No pest reduction methods were in the room at this time. There were more than a dozen flies in R49's room at this time.R54's Facesheet printed on 7/22/25 showed R54 is a [AGE] year-old male with diagnoses which include intracranial injury with loss of consciousness, quadriplegia, and dysphagia.On 7/21/25 at 2:10 PM, R54 was in his room resting in reclined wheelchair. R54 had several flies landing on his face and crawling across his nose and cheek. R54 would flex his arm, but due to quadriplegia was unable to scare flies away.On 7/22/25 at 10:30 AM, V16 pest control specialist (3rd party) stated they do have treatments for flies, but they cannot utilize them in resident rooms. The main treatment is a chemical spray in open areas. The resident rooms are maintained by the facility. If we are told a certain room or hallway has pests (flies) we can go and give recommendations to reduce the issue. V16 stated they have not had anyone direct them to any specific resident rooms for pest (flies) control concerns.On 7/23/25 at 10:20 AM, V10 Safety Director stated if any of the staff notice a bug issue (ants, flies, etc.) they need to let me know so we can try to reduce the issue and let the pest control group about the problem when they come in. V10 stated he was not notified about R46 and R54's fly problem. There should not be flies crawling on residents. The facility's Pest Control Policy dated 2025 showed the facility is to maintain an effective pest control program that contains common household pests including bed bugs, ice, roaches, ants, mosquitos, flies, mice, and rats. Residents Affected - Few 145556 Page 13 of 13